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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date March 5, 2018 <br />Name Scott Kreeger <br />Department <br />Division/Bureau <br />Public Works <br />Engineering <br />B,PW Date March '13, 2018 Phone Extension 9245 <br />Required Prior to Submittal to Board <br />Legal Attorney Name: Clara McDaniels, <br />Controller El Controller review is required for all Contracts $5,000.00 or more and <br />greater than one year in Ilength per the City Purchasing Policy <br />Purchasing 1:1 <br />Check the Appropriate Item Type — Required forAH Submissions <br />Agreement Amendment R Contract El Proposal E] Addendum <br />F-1 Professional Services R Resolution <br />R Bid Opening El Bid Award Req. to Advertise El Title Sheet <br />R Quote Opening El Quote Award <br />El Change Order No. FIC/O & PCA No. 0 PCA <br />E] Ease/Encroach. R Traffic Control: <br />El Other: <br />Required Information <br />Company or Vendor Name <br />New Vendor <br />MBEANBE Contractor <br />MBENVBE Contractor Requested <br />Project Name <br />Project Number <br />Funding Source <br />Account No. <br />Amount <br />Terms of Contract <br />Purpose/Description <br />10hy-ME101 JUSITZ-0 0 mf <br />2018 Streets and Sewers Department Materials <br />118-031 <br />Streets, Curb & Sidewalk, Sewer Concrete, Sewer Ins, Water Works, <br />Parks <br />202-0607-431.22-24, .22-30,.22-40, .23-02, 23-03, 23-20, 23-40, .39- <br />89, 641-0621-792.22-24, .23-02, .23-03, .23-04, 202-0619-431,23-03, <br />.23-2,4, 641-0625-792,22-24, .23-04, 640-0620-811.22-24, .23-04, <br />620-0640-61016.23-30, 201-1101-452.39-89 (Proi. Code K61 RMT) <br />Unit Price <br />Purchase of materials for Street and Sewer Departments <br />" Required Contractor's Certification Forms Attached (Non - <br />Collusion, Non -Discrimination, Non -Debarment, E-Verify, Iran, etc.) <br />Required For Change Orders Only <br />all L UOV= <br />El Increase $ <br />Amount of [] Decrease $ <br />Previous Amount <br />Current Percent of Change <br />New Amount <br />Total Percent of Change; <br />Copy <br />Original <br />N <br />El <br />H <br />F] <br />E <br />El <br />E11 <br />Kara Boyles, <br />Roger Nawrot <br />Derick Roberts <br />DisDersal After Ar)r)roval <br />